Reimbursement Assistance

For coding questions and reimbursement issues, contact Sandie at 408/998-8850 or MCMS 831/455-1008 or email sandie@sccma.org. Also, contact Sandie if you would like to receive the Coding & Reimbursement Newsletter by email.

Reimbursement Advocacy Program (RAP) is a benefit available only to members of the Santa Clara County Medical Association and Monterey County Medical Society. Through RAP, association members gain leverage in collecting payments from managed care plans (and other payers) slow in honoring claims. The RAP program also provides physicians, their office managers, and/or billing staff with coding and billing guidance.

Carrier Failure to Process “Clean Claims” in Accordance With State Law (30 days for PPO plans and 45 days for HMOs)

Habitual Downcoding

Treatment Authorization and Subsequent Denial

Payment Inconsistent With the Physician’s Contract and CPT Guidelines

Coding Guidance

Follow These Steps To Expedite In-Office Collection:

Step #1: Collect Accurate Data

Remember—collection of accurate data is vital to your practice. Verify the information below at every patient encounter:

HMO or IPA affiliation

Name of insurance company

Name of Primary Care Physician (PCP)—with some plans this information can change monthly

Patient’s home address. Do not accept a P.O. Box, in lieu of a home address

Patient’s phone number

Address and phone number of patient’s current employer

If the patient visit requires a referral from a PCP, secure the referral number prior to the patient visit

Step #2: Discuss Fees and Billing Procedures With Your Patients

It is very important to inform new patients about billing policies, when they call for an appointment. Place a sign at the check-in area advising patients that co-pays and deductibles are due at the time of service. Also, incorporate these policies in your patient registration form. Collect any applicable co-pays and/or unmet deductibles at patient checkout. Strict adherence to the foregoing will eliminate the additional expense of follow-up billing. Consistent observance of the “pay at time of service” policy not only reduces overhead, but reinforces the custom with patients, resulting in their readiness to pay prior to leaving the office.

Step #3: Electronic Billing

Claims should be filed electronically, whenever possible. This practice will significantly expedite payments and save resources, i.e. staff time, supplies, postage. In order to ensure timely reimbursement, whether billing electronically or via submission of paper claims, it is imperative that claims are “clean” and accurate, i.e. employ proper use of CPT procedure codes, modifiers, and ICD-9 diagnosis codes. The availability of up-to-date coding manuals, familiarity with current coding literature, augmented with attendance at billing-related seminars, are essential tools for precise billing.

Step #4: Obtain “Physician Claims Inquiry” Forms From SCCMA/MCMS

These bright green forms, identified with the SCCMA/MCMS logo, garner excellent results when affixed to claims that seem to be “hung-up” in the system. Attach this attention-getting form to a copy of the original claim(s) and resubmit to the carrier—30 days after the first submission for PPOs and 45 days for HMOs.

Step #5: Request Help From SCCMA/MCMS RAP

After 30-45 days, if there is no response to the “Physician Claims Inquiry,” complete and sign an RAP form, and attach a copy of the claim, the patient’s insurance card, along with any related correspondence, and mail to: